Healthcare Provider Details

I. General information

NPI: 1558796896
Provider Name (Legal Business Name): MUCCIOLI DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 HOSPITAL PKWY SUITE 275
JOHNS CREEK GA
30097-1828
US

IV. Provider business mailing address

6300 HOSPITAL PKWY SUITE 275
JOHNS CREEK GA
30097-1828
US

V. Phone/Fax

Practice location:
  • Phone: 678-389-9955
  • Fax: 678-389-9952
Mailing address:
  • Phone: 678-389-9955
  • Fax: 678-389-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN014378
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN014379
License Number StateGA

VIII. Authorized Official

Name: DR. RANDY EARL MUCCIOLI
Title or Position: OWNER/DENTIST
Credential: D.M.D
Phone: 678-389-9955